A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.
The nurse determines that the amniotic fluid is clear and odorless.
Besides notifying the provider, which of the following is the appropriate first nursing action?
Allow the client to ambulate in the hallway to initiate labor.
Encourage oral fluids and administer an antipyretic medication.
Administer glucocorticoids intramuscularly.
Check the client's temperature every 2 hours.
The Correct Answer is D
Choice A rationale
Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.
Choice B rationale
Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.
Choice C rationale
Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.
Choice D rationale
Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition: The client is likely experiencing PPROM, as evidenced by the sudden gush of clear fluid and continued light leakage, confirmed by fluid pooling in the vaginal vault that tested positive for ferning. PPROM can lead to preterm labor and increased risk of infection. The absence of contractions or bleeding, and the mild lower abdominal discomfort, further supports this diagnosis.
Rationale for actions: Administering prophylactic antibiotics helps prevent infection, which is a significant risk with PPROM. Educating the client on kick counts ensures monitoring of fetal well-being. Preparing for an emergent C-section is not immediately necessary as the cervix is closed. Providing IV fluids for hypotension is not applicable here as blood pressure is elevated. Discharging the client with follow-up in one week is inappropriate given the risk of infection and preterm labor.
Rationale for parameters: Monitoring signs of infection is crucial, as PPROM increases infection risk. Maternal blood pressure trends must be watched due to elevated readings, suggesting possible complications. Meconium-stained amniotic fluid, while concerning, is not present. Maternal platelet levels and fundal height measurements do not directly address the current risks associated with PPROM.
Rationale for incorrect conditions: Placental abruption typically involves abdominal pain and bleeding, which are absent. Preeclampsia involves hypertension and proteinuria, but no significant proteinuria is present. Oligohydramnios involves decreased amniotic fluid, but the client reports clear fluid leakage indicating rupture of membranes.
Correct Answer is C
Explanation
Choice A rationale
Hydration is important for maintaining maternal fluid balance and energy during labor, but it does not specifically address the severe backache experienced by the client.
Choice B rationale
Amniotomy can stimulate labor progression but is not specifically indicated for relieving back pain associated with labor.
Choice C rationale
Counterpressure to the sacrum can help alleviate back pain during labor, especially if the baby is in an occiput posterior position, which causes severe backache. Applying pressure to the sacrum can provide relief and comfort to the laboring client.
Choice D rationale
Urinary catheterization may be necessary if the client is unable to void, but it does not address the primary issue of severe back pain during labor.
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